Thoracic Endovascular Aortic Repair (TEVAR) Indications and Basic Procedure Tilo Kölbel, MD, PhD University Heart Center Hamburg University Hospital Eppendorf
Disclosure Speaker name: Tilo Kölbel, MD I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company X Other: Proctoring, travel, research-grants, patents with Cook Medical I do not have any potential conflict of interest
History Michael Dake, Radiologist, Stanford, USA First clinical report on TEVAR 1994: Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysm Dake et al. 1994; N Engl J Med 331:1729-34
Descending Aorta: Open Repair vs. TEVAR Metaanalysis of comparative studies TAA and dissection (n = 5888) TEVAR better: 30d mortality Paraplegia Transfusion Cardiac and resp. compl. Kidney function Reintervention Hospital and ICU stay Cheng at al. 2010; JACC 55: 986-1001
Disease Specific Indication Aneurysm Dissection Transsection Coarctation
Thoracic Aortic Aneurysm Operative treatment (TEVAR) if: Diameter > 5.5-6cm Diameter growth >0.5-1cm/year Symptoms: Pain Local compression Rupture Aneurysm
Type B Aortic Dissection Operative treatment (TEVAR) if: Acute: Malperfusion: visceral, renal, peripheral Rupture and hemorrhage Early dilatation, other prognostic factors Chronic: False-lumen aneurysm > 5.5-6cm False-lumen aneurysm growth > 0.5-1cm/year Claudication, rupture and hemorrhage
Type B Aortic Dissection
Traumatic Aortic Rupture Operative treatment (TEVAR) if: Grade 2-lesion (intramural hematoma) Grade 3-lesion (pseudoaneurysm) Grade 4-lesion (hemorrhage)
Coarctation Operative treatment (TEVAR) if: Symptoms: Claudication Headache peak-to-peak gradient of >20 mm Hg at rest or >30 mmhg after exercise. Left Ventricular dysfunction and hypertrophy Refractory hypertension
Standard Procedure Efficacy Costs Time Mistakes
Planning Most technical Errors follow insufficient planning!
Workstation
Access Mikropunktionsset: 27 G Nadel 0.018 Draht 2 Hülsen
Access
Access 6F-sheath for access-side Heparine 100IU/kg, ACT Stiff double-curved wire into ascending aorta Angio catheter into arch from contralateral femoral artery or brachial artery Serial Dilators
Iliac Conduit
Paving and Cracking
Through&Through-Wire Stiff Guidewire Soft transbrachial Throughwire
Graft Preparation Remove peel-away, mandrin, etc. Fasten screws, stop-cocks. Flush central lumen and graft. Follow graft-specific instructions.
Arch-angiography
Arch-angiography
Proximal Deployment
Component Overlap Overlap 5cm in TAA 2cm in dissection
Distal Deployment
Dilatation Compliant Balloon
Final Angiography Reposition pigtail Overview Apnea Late images
Access Closure Percutaneous Open surgical Fascial Closure Technique
Summary Rapid development of devices, techniques, and operator skills. TEVAR is the standard of care for lesions in the descending thoracic aorta. Preoperative planning, device-selection and sizing of TEVAR is mandatory. Endovascular treatment will continue to challenge open surgery also for lesions of the aortic arch and the ascending aorta.
Thoracic Endovascular Aortic Repair (TEVAR) Indications and Basic Procedure Tilo Kölbel, MD, PhD University Heart Center Hamburg University Hospital Eppendorf